Care Transitions and Peer Support for Hospital Readmission
Trial Summary
What is the purpose of this trial?
Unplanned hospital readmissions are extremely costly to patients and our healthcare system. Being readmitted to the hospital also leads to increased risk of health complications for patients including infections and impairments in functioning. Hospital readmissions are particularly common among older adults. Further, racial/ethnic disparities are evident in readmission rates and are the greatest among African American and Latino/Hispanic older adults. Effective, sustainable, and culturally appropriate interventions to improve outcomes, reduce unplanned hospital readmissions, and reduce health disparities are urgently needed. The proposed randomized controlled trial will evaluate the effectiveness of a novel transitional care strategy designed to avoid unplanned hospital readmissions and improve patient health outcomes in a racially/ethnically diverse sample of older adults who have been admitted to the hospital due to a chronic health condition. Eric Coleman's Care Transitions Intervention (CTI) has been identified as the strategy most successfully implemented and evaluated in multiple settings and systems of care. CTI has been shown to reduce hospital readmissions for non-Hispanic White older adults, however its' effects have not been as strong for minority older adults in some studies and research trials have not recruited a sufficient number of racial/ethnic minorities to examine outcomes by race or ethnicity. Thus, it is unknown whether CTI is effective for racial/ethnic minority older adults who suffer disproportionately high readmission rates. Further, studies of transitions interventions suggest that older adult and racial/ethnic minority patients require additional assistance and support during transitions in care. The researchers hypothesize the addition of peer support will enhance and maximize the benefit of the CTI and increase its' cultural sensitivity and future sustainability. The proposed 3-arm trial is designed to evaluate the Care Transitions Intervention (CTI) and CTI + Peer Support (PS), as compared to usual care (UC), on unplanned all-cause hospital readmissions occurring within 6 months (assessed at 30 days, 90 days and 6 months) and secondary health system (i.e., ED visits) and patient-centered outcomes (i.e., self-efficacy managing chronic disease, quality of life, functional status and mortality) among 402 hospitalized African American and Latino/Hispanic older adults (age 60+) who have a chronic physical illness (e.g., cardiovascular disease, diabetes, COPD) and are being discharged from the hospital back to the community.
Will I have to stop taking my current medications?
The trial information does not specify whether you need to stop taking your current medications. It is best to discuss this with the trial coordinators or your healthcare provider.
What data supports the effectiveness of the treatment Care Transitions Intervention and Peer Support for reducing hospital readmissions?
Research shows that care transition interventions, which include patient and caregiver engagement, medication management, and education, can effectively reduce hospital readmissions. For example, a study on heart failure patients found that a care transitions intervention reduced readmission rates from 24% to 13%.12345
Is the Care Transitions and Peer Support treatment generally safe for humans?
The research highlights that care transitions, such as moving from hospital to home, can be a high-risk period for adverse events (unintended harm from medical care), especially related to medication safety. However, these studies focus on identifying risks and improving processes rather than directly evaluating the safety of the Care Transitions and Peer Support treatment itself.678910
How does the Care Transitions Intervention and Peer Support treatment differ from other treatments for hospital readmission?
The Care Transitions Intervention and Peer Support treatment is unique because it focuses on improving communication and coordination between hospital staff, patients, and community providers to reduce hospital readmissions. It includes coaching and peer support, which are not typically part of standard care, to help patients transition smoothly from hospital to home.1112131415
Research Team
Amber M Gum, Phd
Principal Investigator
University of South Florida
Eligibility Criteria
This trial is for African American and Latino/Hispanic older adults aged 60+ with chronic illnesses like heart disease, diabetes, or COPD. Participants must be discharged from one of the three partner hospitals to their home without planned readmissions and have access to a phone. They should speak English or Spanish.Inclusion Criteria
Timeline
Screening
Participants are screened for eligibility to participate in the trial
Care Transitions Intervention (CTI)
Participants receive the Care Transitions Intervention, a non-clinical coaching strategy that occurs in the hospital, home, and via telephone for 28 days post-discharge
Care Transitions Intervention and Peer Support (CTI + PS)
Participants receive the Care Transitions Intervention enhanced with peer support to improve outcomes among racial/ethnic minority older adults
Follow-up
Participants are monitored for unplanned hospital readmissions and secondary health outcomes at 30 days, 90 days, and 6 months
Treatment Details
Interventions
- Care Transitions Intervention
- Care Transitions Intervention and Peer Support
- Usual Care
Find a Clinic Near You
Who Is Running the Clinical Trial?
University of South Florida
Lead Sponsor
Tampa General Hospital
Collaborator
Lakeland Regional Health Medical Center
Collaborator
Patient-Centered Outcomes Research Institute
Collaborator
AdventHealth
Collaborator